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LESLIE L DAVIS, PHD, RN, ANP-BC, FAANP, FAHA
ADULT NURSE PRACTITIONER
ASSOCIATE PROFESSOR OF NURSING
Heart Failure: How to Incorporate the Latest Guidelines Into Your Practice
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Disclosures I have no disclosures relevant to this presentation.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Topics to Cover▪Discuss implications of recent clinical practice guidelines of pharmacologic treatment of heart failure (HF) with reduced ejection fraction.
▪Determine how to titrate optimal therapy using the most appropriate pharmacologic agents for treating adults with reduced ejection fraction.
▪Review what circumstances would trigger a referral to a HF specialist.
▪Share new tools available for clinicians who treat patients with HF
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Definition: Heart failure with Reduced Ejection Fraction
▪Clinical diagnosis of heart failure and a left ventricular ejection fraction of 40% or less
▪Abbreviated as HFrEF
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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of
HF treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert
Consensus Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Established Therapies for Chronic HF•Angiotensin Converting Enzyme inhibitors (ACE-Is)
•Angiotensin receptor blockers (ARBs)
•Beta-blockers (only the ones approved)
•Loop diuretics
•Aldosterone antagonists
•Hydralazine/isosorbide dinitrate (HYD/ISDN)
•All (except loop diuretics) have been shown to improve symptoms, reduce hospitalization, and/or help patients live longer.
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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF
treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus
Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
New treatment Guidelines for Heart Failure with Reduced Ejection Fraction
•Updated recommendations on biomarkers*
•Two new medications for patients with HFrEF*• Angiotensin receptor neprilysin inhibitor (ARNI) (sacubitril/valsartan)
• Sinoatrial node modulator (ivabradine)
•Info on heart failure with preserved ejection fraction (HFpEF)
•Info on comorbidities including sleep apnea, anemia and hypertension
•Insights regarding HF prevention *We will focus on these for this presentation (about HF with reduced EF)
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Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the
management of HF: a report of the ACC/AHA Task Force on Clinical Practice Guidelines & the HFSA. Circulation. doi:
10.1161/CIR.0000000000000509.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Updated recommendations on biomarkers: PREVENTION
•For patients at risk of developing HF, natriuretic peptide biomarker–based screening followed by team-based care (including a cardiovascular specialist optimizing GDMT) can be useful to prevent the development of left ventricular dysfunction (systolic or diastolic) or new onset HF.
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Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the
management of HF: a report of the ACC/AHA Task Force on Clinical Practice Guidelines & the HFSA. Circulation. doi:
10.1161/CIR.0000000000000509.
Includes B-type natriuretic peptide (BNP) or
N-terminal pro-B-type natriuretic peptide (NT-proBNP)
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Updated recommendations on biomarkers: DIAGNOSIS
In patients presenting with dyspnea, measurement of natriuretic peptide biomarkers is useful to support a diagnosis or exclusion of HF .
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Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the
management of HF: a report of the ACC/AHA Task Force on Clinical Practice Guidelines & the HFSA. Circulation. doi:
10.1161/CIR.0000000000000509.
Includes B-type natriuretic peptide (BNP) or
N-terminal pro-B-type natriuretic peptide (NT-proBNP)
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Updated recommendations on biomarkers: Prognosis
•Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF (unchanged from 2013)•Measurement of baseline levels of natriuretic peptide biomarkers and/or cardiac troponin on admission to the hospital is useful to establish a prognosis in acutely decompensated HF (modified)•During a HF hospitalization, a predischarge natriuretic peptide level can be useful to establish a post-discharge prognosis (new)
•In patients with chronic HF, measurement of other clinically available tests, such as biomarkers of myocardial injury or fibrosis, may be considered for additive risk stratification (modified)
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Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the
management of HF: a report of the ACC/AHA Task Force on Clinical Practice Guidelines & the HFSA. Circulation. doi:
10.1161/CIR.0000000000000509.
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 10
Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF
treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus
Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment
Writing CommitteeClyde W. Yancy, MD, MSC, MACC, Chair
James L. Januzzi, JR, MD, FACC, Vice Chair
Larry A. Allen, MD, MHS, FACC
Javed Butler, MD, MBA, MPH, FACC
Leslie L. Davis, PHD, RN, ANP-BC
Gregg C. Fonarow, MD, FACC
Nasrien E. Ibrahim, MD, FACC
Mariell Jessup, MD, FACC
JoAnn Lindenfeld, MD, FACC
Thomas M. Maddox, MD, MSC, FACC
Frederick A. Masoudi, MD, MSPH, FACC
Shweta R. Motiwala, MD
J. Herbert Patterson, PHARMD
Mary Norine Walsh, MD, FACC
Alan Wasserman, MD, FACC
Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, &
et al 2017 ACC expert consensus decision pathway for
optimization of HF treatment: answers to 10 pivotal
issues about HF with reduced EF: a report of the ACC
Task Force on Clinical Expert Consensus Decision
Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Treatment Algorithm for Guideline-Directed Medical Therapy Including Novel Therapies
Excerpted from:
Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure with Reduced Ejection Fraction
December 2017
DOI: 10.1016/j.jacc.2017.11.025
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Beta Blockers
Drug Starting Dose
Bisoprolol 1.25 mg q day
Carvedilol 3.125 mg bid
Metoprolol succinate 12.5-25 mg q day
Target Dose
10 mg q day
25 mg bid (if wt < 85 kg); otherwise 50 mg bid
200 mg daily
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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF
treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus
Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
ACE-I (some examples)
Drug Starting Dose
Captopril 6.25 mg tid
Enalapril 2.5 mg bid
Lisinopril 2.5-5 mg daily
Ramipril 1.25 mg q day
Target Dose
50 mg tid
10- 20 mg bid
20 - 40 mg daily
10 mg daily
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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF
treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus
Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
ARBs (some examples)
Drug Starting Dose
Candesartan 4 – 8 mg q day
Losartan 25 – 50 mg q day
Valsartan 40 mg bid
Target Dose
32 mg daily
150 mg daily
160 mg twice daily
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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF
treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus
Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Aldosterone Antagonists
Drug Starting Dose
Eplerenone 25 mg q day
Spironolactone 12.5 - 25 mg q day
Target Dose
50 mg q day
25 – 50 mg q day
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• New recommendation: Aldosterone antagonists may reduce hospitalizations in some patients with HFpEF.
• Important: Monitor kidney function and potassium within 2-3 days, again at 7 days
Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF
treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus
Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
VasodilatorsDrug Starting Dose Target Dose
Hydralazine 25 mg tid 75 mg tid
Isosorbide DN 20 mg tid 40 mg tid_______
Fixed dose combo 20 mg/3.75 mg(one tab) tid 2 tabs tid
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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF
treatment: answers to 10 pivotal issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus
Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Sacubitril/Valsartan (ARNI)
Indications• HFrEF (EF < 40%)
• NYHA Class II or IV
Contraindications
Cautions
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1. Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC
expert consensus decision pathway for optimization of HF treatment:
answers to 10 pivotal issues about HF with reduced EF: a report of the
ACC Task Force on Clinical Expert Consensus Decision Pathways. J Am
Coll Cardiol 2018;71(2): 201-230.
2. ENTRESTO [prescribing information]. East Hanover, NJ: Novartis
Pharmaceuticals Corp; November 2018.
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Sacubitril/Valsartain (ARNI)
Starting dose: 24/26 mg – 49/51 mg twice daily• When to start with lower dose
• When to start with higher dose
Target dose: 97/103 mg twice daily
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Conversion of ACE-I to ARNI (*Sacubitril/valsartan)
•Need 36-hour washout period of ACE-I to avoid angioedema• Would not need to do this if on an ARB
•Ensure the patient has an adequate BP (contraindicated if symptomatic hypotension or decompensated)
•eGFR <30 mL/min/1.73 m2
•Starting dose• If taking < 10 mg enalapril (or equivalent) start with 24/26 mg twice daily• If taking > 10 mg enalapril (or equivalent) start with 49/51 mg twice daily
•Reassess in 2-4 weeks
•If tolerates, up-titrate to 97/103 mg twice daily
•Ongoing monitoring (BP, electrolytes/kidney function after initiation and each up titration)
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Ivabradine
Indications: • HFrEF (EF < 35%)• On maximum tolerated doses of
beta-blocker• Sinus rhythm with resting HR of > 70 bpm• NYHA Class II or III HF
ContraindicationsCautions
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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC
expert consensus decision pathway for optimization of HF treatment:
answers to 10 pivotal issues about HF with reduced EF: a report of the
ACC Task Force on Clinical Expert Consensus Decision Pathways. J Am
Coll Cardiol 2018;71(2): 201-230.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
IvabradineStarting dose: 2.5 – 5 mg twice daily• Lower dose if hx of conduction defects or Age > 75
Target dose: titrate to heart rate 50-60 beats/per/minute.
Maximum dose: 7.5 mg twice daily
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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal
issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Pearls for Starting TherapyFor new patients:• Starting ACE-I or ARBS = often better tolerated if
started when a little “wet”
• Starting beta-blockers = often better tolerated if started when a little “dry” (as long as heart rate is adequate)
• Could start both (low doses)
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
What’s the Role of Digoxin?
•No survival benefit
•When to start digoxin
•Dosing is tricky, esp in patients with kidney disease
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
HF with Preserved Ejection Fraction In appropriately selected patients with HFpEF (with EF ‡45%, elevated BNP levels or HF admission within 1 year, estimated glomerular filtration rate >30 mL/min, creatinine clearance < 2.5 mg/dL, potassium < 5.0mEq/L), aldosterone receptor antagonists might be considered to decrease hospitalization.
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Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the
management of HF: a report of the ACC/AHA Task Force on Clinical Practice Guidelines & the HFSA. Circulation. doi:
10.1161/CIR.0000000000000509.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Excerpted from:
Optimization of Heart FailureTreatment: Answers to 10 PivotalIssues About HeartFailure with ReducedEjection Fraction
December 2017DOI: 10.1016/j.jacc.2017.11.025
Evaluation of the patient with heart failure
Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et al 2017 ACC expert consensus decision pathway for optimization of HF treatment: answers to 10 pivotal
issues about HF with reduced EF: a report of the ACC Task Force on Clinical Expert Consensus Decision Pathways. J Am Coll Cardiol 2018;71(2): 201-230.
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Triggers for HF Patient Referral to HF Program (or Specialist)•New onset HF
•Chronic HF with high risk features
•To assist with managing guideline directed medical therapy (GDMT)
•Persistently reduced LVEF (< 35%) despite GDMT for > 3 months
•Need 2nd opinion
•Annual review for established HF patients with advanced disease
•Participation in a clinical trial
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Yancy CW, Januzzi JL Jr, Allen LA, Butler J, Davis LL, & et
al 2017 ACC expert consensus decision pathway for
optimization of HF treatment: answers to 10 pivotal issues
about HF with reduced EF: a report of the ACC Task Force
on Clinical Expert Consensus Decision Pathways. J Am
Coll Cardiol 2018;71(2): 201-230.
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Case study
55-year-old male with HFrEF who has been seen in your HF clinic for past 6 months.
PMH: Hx of 2 vessel coronary heart disease
Last LVEF: 30% (after being on a stable dose of meds for ~4 months)
Functional heart class: NYHA Class III
Weight: 75 kg (euvolemic)
Blood pressure 110/70 (lying & standing)
HR 66 beats per min
Labs: K+ 4.0, BUN 10, Creat 1.4
Current meds:• Ramipril 10 mg daily• Carvedilol 25 mg bid• Furosemide 40 mg bid• Spironolactone 25 mg bid
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Case study continuedIs he on guideline directed medical therapy (GMDT)?
Are each of the meds at target dose?
What other treatment could be added (since he remains symptomatic)?• Switch ACE-I to ARNI?
• Add Ivabradine?
• Add Hydralazine/Isosorbide dinitrate?
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
New ACC Expert Consensus Decision PathwayPublished 9/13/19 online ahead of print
Hollenberg SM, Stevenson LW, Ahmad T, et al. 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of PatientsHospitalized With Heart Failure. J Am Coll Cardiol. Published online September 13, 2019. DOI: 10.1016/j.jacc.2019.08.001.
Focus on course of HF admission
•1st ED visit, hosp admission, trajectory check, transition to oral therapies, discharge, & 1st
discharge contact followed by 1st
discharge visit
Several algorithms, tables, worksheets
Stresses communication:
•Among team members, esp surrounding hospital discharge
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Example of a Shared Decision-making Tool for ICDs (page 3 of 8)
https://www.cardiosmart.org/SDM/Decision-Aids/Find-Decision-Aids/ICD
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
New Resources Avail: https://www.cardiosmart.org/MyHFActionPlan
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 34
Other Tools to Use: https://www.acc.org/tools-and-practice-support/quality-programs/succeed-in-managing-heart-failure-initiative
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THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING
Questions?
Leslie Davis
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